User login
Society of Hospital Medicine Builds Awareness of HM Career Benefits
It’s that time of year again. Across the country, thousands of students are starting medical school. And in just a short time—it goes faster than you think—they’ll be faced with the decision of what specialty they want to pursue.
To make that decision, these students will have to consider a variety of factors beyond their personal interests, including the training, compensation, lifestyle, and career path associated with each specialty.
When I was in medical school, hospital medicine wasn’t a career option—our field didn’t even exist. I remember going through the decision process like it was yesterday. The first two years, as you know, provide little exposure to the true day-to-day challenges and lifestyle of any of the potential choices. That time comes in the third and fourth years, and many students are forced to make a decision after experiencing only a few of the myriad possibilities.
My personal experience with this process was quite a wandering path. I began medical school with tunnel vision around becoming an orthopedic surgeon. I struggled through the first two years of physiology and embryology and the like, eager to get my hands on the “tools” of a real surgeon.
Gradually, I moved away from that plan as I witnessed firsthand how grueling the residency training was and how it personally impacted those residents I knew and their families. I was briefly tempted by a vascular surgery attending who offered to take me under his wing, but I soon came to my senses.
I then gravitated toward specialties that were less technical and more intellectual. After a very enjoyable third-year pediatrics rotation, I could clearly see myself taking care of “little people.” Internal medicine challenged me with the most interesting of clinical conundrums, and I began to see myself solving great mysteries. Family medicine gave me a nice mix of both, and that is where I eventually settled. Having the option of hospital medicine would certainly have made the choice more difficult for me. The attraction would have been, and frankly, still is, the combination of caring for the patient and the system simultaneously.
A Career Choice
Today, hospital medicine is medicine’s fastest growing field. Unfortunately, many young physicians don’t think about hospital medicine when planning their careers. It’s often considered a brief stop between residency and a fellowship—a way to make some money and pay back medical school loans before continuing toward a career in a specialty like cardiology, gastroenterology, or hematology.
That’s why SHM has been making a concerted effort to increase awareness among medical school students about the benefits of a career in hospital medicine. We have launched several programs geared specifically to medical students and residents.
For example, SHM has built a “Future of Hospital Medicine” website for students and residents, filled with information about what it’s like to have a career in hospital medicine. Plus, we now offer free membership dues and electronic access to our publications for medical students who want to join SHM.
SHM launched the “Future of Hospital Medicine” (FOHM) campaign in 2013 under then-President Dr. Eric Howell’s leadership. Since then:
- Student membership has increased 217%;
- Resident/fellow membership has increased by 97%;
- We’ve conducted five “FOHM” live events in Philadelphia, New York, Baltimore, and Chicago (twice) and will be hosting another event in Los Angeles this fall; and
- We offer more focused student and resident content at HM15, as well as the largest attendance to date for both groups.
We also recently developed the Society of Hospital Medicine Student Hospitalist Scholar Grant program. Through the program, eligible students can receive a $5,000 summer stipend for scholarly work on a project related to patient safety/quality improvement or other areas relevant to the field of hospital medicine. The program also provides up to $1,500 in travel-related reimbursement for the student attending the SHM annual meeting.
This year, the grant program’s first, three students are participating in summer research on topics that include post-hospital syndrome and physiologic alarm responses. You can follow their progress on the SHM blog. Eventually, we expect the program to grow to 10 grantees every summer.
Awareness Is Key
We hope efforts like these will help raise awareness and interest in hospital medicine and SHM among medical students and young physicians. Although our field is relatively young, it’s full of opportunities for building a rewarding, lasting career.
Hospital medicine is so much more than a medical pit stop. As we know at SHM, it’s a specialty in which young physicians can launch and build a sustainable career.
If you are a career hospitalist, I ask you to help spread the word. And, if you are a student contemplating your future, I invite you to visit us and learn more. I know you will not be disappointed.
It’s that time of year again. Across the country, thousands of students are starting medical school. And in just a short time—it goes faster than you think—they’ll be faced with the decision of what specialty they want to pursue.
To make that decision, these students will have to consider a variety of factors beyond their personal interests, including the training, compensation, lifestyle, and career path associated with each specialty.
When I was in medical school, hospital medicine wasn’t a career option—our field didn’t even exist. I remember going through the decision process like it was yesterday. The first two years, as you know, provide little exposure to the true day-to-day challenges and lifestyle of any of the potential choices. That time comes in the third and fourth years, and many students are forced to make a decision after experiencing only a few of the myriad possibilities.
My personal experience with this process was quite a wandering path. I began medical school with tunnel vision around becoming an orthopedic surgeon. I struggled through the first two years of physiology and embryology and the like, eager to get my hands on the “tools” of a real surgeon.
Gradually, I moved away from that plan as I witnessed firsthand how grueling the residency training was and how it personally impacted those residents I knew and their families. I was briefly tempted by a vascular surgery attending who offered to take me under his wing, but I soon came to my senses.
I then gravitated toward specialties that were less technical and more intellectual. After a very enjoyable third-year pediatrics rotation, I could clearly see myself taking care of “little people.” Internal medicine challenged me with the most interesting of clinical conundrums, and I began to see myself solving great mysteries. Family medicine gave me a nice mix of both, and that is where I eventually settled. Having the option of hospital medicine would certainly have made the choice more difficult for me. The attraction would have been, and frankly, still is, the combination of caring for the patient and the system simultaneously.
A Career Choice
Today, hospital medicine is medicine’s fastest growing field. Unfortunately, many young physicians don’t think about hospital medicine when planning their careers. It’s often considered a brief stop between residency and a fellowship—a way to make some money and pay back medical school loans before continuing toward a career in a specialty like cardiology, gastroenterology, or hematology.
That’s why SHM has been making a concerted effort to increase awareness among medical school students about the benefits of a career in hospital medicine. We have launched several programs geared specifically to medical students and residents.
For example, SHM has built a “Future of Hospital Medicine” website for students and residents, filled with information about what it’s like to have a career in hospital medicine. Plus, we now offer free membership dues and electronic access to our publications for medical students who want to join SHM.
SHM launched the “Future of Hospital Medicine” (FOHM) campaign in 2013 under then-President Dr. Eric Howell’s leadership. Since then:
- Student membership has increased 217%;
- Resident/fellow membership has increased by 97%;
- We’ve conducted five “FOHM” live events in Philadelphia, New York, Baltimore, and Chicago (twice) and will be hosting another event in Los Angeles this fall; and
- We offer more focused student and resident content at HM15, as well as the largest attendance to date for both groups.
We also recently developed the Society of Hospital Medicine Student Hospitalist Scholar Grant program. Through the program, eligible students can receive a $5,000 summer stipend for scholarly work on a project related to patient safety/quality improvement or other areas relevant to the field of hospital medicine. The program also provides up to $1,500 in travel-related reimbursement for the student attending the SHM annual meeting.
This year, the grant program’s first, three students are participating in summer research on topics that include post-hospital syndrome and physiologic alarm responses. You can follow their progress on the SHM blog. Eventually, we expect the program to grow to 10 grantees every summer.
Awareness Is Key
We hope efforts like these will help raise awareness and interest in hospital medicine and SHM among medical students and young physicians. Although our field is relatively young, it’s full of opportunities for building a rewarding, lasting career.
Hospital medicine is so much more than a medical pit stop. As we know at SHM, it’s a specialty in which young physicians can launch and build a sustainable career.
If you are a career hospitalist, I ask you to help spread the word. And, if you are a student contemplating your future, I invite you to visit us and learn more. I know you will not be disappointed.
It’s that time of year again. Across the country, thousands of students are starting medical school. And in just a short time—it goes faster than you think—they’ll be faced with the decision of what specialty they want to pursue.
To make that decision, these students will have to consider a variety of factors beyond their personal interests, including the training, compensation, lifestyle, and career path associated with each specialty.
When I was in medical school, hospital medicine wasn’t a career option—our field didn’t even exist. I remember going through the decision process like it was yesterday. The first two years, as you know, provide little exposure to the true day-to-day challenges and lifestyle of any of the potential choices. That time comes in the third and fourth years, and many students are forced to make a decision after experiencing only a few of the myriad possibilities.
My personal experience with this process was quite a wandering path. I began medical school with tunnel vision around becoming an orthopedic surgeon. I struggled through the first two years of physiology and embryology and the like, eager to get my hands on the “tools” of a real surgeon.
Gradually, I moved away from that plan as I witnessed firsthand how grueling the residency training was and how it personally impacted those residents I knew and their families. I was briefly tempted by a vascular surgery attending who offered to take me under his wing, but I soon came to my senses.
I then gravitated toward specialties that were less technical and more intellectual. After a very enjoyable third-year pediatrics rotation, I could clearly see myself taking care of “little people.” Internal medicine challenged me with the most interesting of clinical conundrums, and I began to see myself solving great mysteries. Family medicine gave me a nice mix of both, and that is where I eventually settled. Having the option of hospital medicine would certainly have made the choice more difficult for me. The attraction would have been, and frankly, still is, the combination of caring for the patient and the system simultaneously.
A Career Choice
Today, hospital medicine is medicine’s fastest growing field. Unfortunately, many young physicians don’t think about hospital medicine when planning their careers. It’s often considered a brief stop between residency and a fellowship—a way to make some money and pay back medical school loans before continuing toward a career in a specialty like cardiology, gastroenterology, or hematology.
That’s why SHM has been making a concerted effort to increase awareness among medical school students about the benefits of a career in hospital medicine. We have launched several programs geared specifically to medical students and residents.
For example, SHM has built a “Future of Hospital Medicine” website for students and residents, filled with information about what it’s like to have a career in hospital medicine. Plus, we now offer free membership dues and electronic access to our publications for medical students who want to join SHM.
SHM launched the “Future of Hospital Medicine” (FOHM) campaign in 2013 under then-President Dr. Eric Howell’s leadership. Since then:
- Student membership has increased 217%;
- Resident/fellow membership has increased by 97%;
- We’ve conducted five “FOHM” live events in Philadelphia, New York, Baltimore, and Chicago (twice) and will be hosting another event in Los Angeles this fall; and
- We offer more focused student and resident content at HM15, as well as the largest attendance to date for both groups.
We also recently developed the Society of Hospital Medicine Student Hospitalist Scholar Grant program. Through the program, eligible students can receive a $5,000 summer stipend for scholarly work on a project related to patient safety/quality improvement or other areas relevant to the field of hospital medicine. The program also provides up to $1,500 in travel-related reimbursement for the student attending the SHM annual meeting.
This year, the grant program’s first, three students are participating in summer research on topics that include post-hospital syndrome and physiologic alarm responses. You can follow their progress on the SHM blog. Eventually, we expect the program to grow to 10 grantees every summer.
Awareness Is Key
We hope efforts like these will help raise awareness and interest in hospital medicine and SHM among medical students and young physicians. Although our field is relatively young, it’s full of opportunities for building a rewarding, lasting career.
Hospital medicine is so much more than a medical pit stop. As we know at SHM, it’s a specialty in which young physicians can launch and build a sustainable career.
If you are a career hospitalist, I ask you to help spread the word. And, if you are a student contemplating your future, I invite you to visit us and learn more. I know you will not be disappointed.
Why Hospitalist Morale is Declining and Ways to Improve It
Using quotes to ensure that the results were only those that include the two words adjacent to one another, rather than separated, I entered the following phrases into my Google search engine:
- “hospitalist burnout” = 1,580 results
- “hospitalist morale” = 208 results
- “hospitalist well-being” = 0 results
I think the number of results suggests the level of interest in each topic and, if that is the case, clearly thinking about how hospitalists are doing in their careers is more commonly done through the paradigm of burnout than the other two terms. (Of course, there may be other terms that I didn’t consider.) In fact, there have been a handful of published studies of hospitalist burnout and job satisfaction.1,2
Those studies generally have shown both reasonably high levels of job satisfaction and troubling levels of burnout.
But I’ve been thinking about hospitalist morale for a while. I think morale is reasonably distinct from both burnout and job satisfaction.
Causes of a National Decline in Hospitalist Morale
I think hospitalist morale has declined some over the past two or three years across the country. This observation is meaningful because it comes from my experience working with a lot of hospitalist groups coast to coast. But I’m the first to admit it is just anecdotal and is subject to my own biases.
I can think of several things contributing to a decline in morale.
EHR adoption. Near the top of the list is the adoption of EHRs in many hospitals, which typically leads doctors in other specialties to seek hospitalist assistance with EHR-related tasks (e.g. medicine reconciliation and order writing) even in cases where there is little or no clinical reason for hospitalist involvement. Lots of hospitalists complain about this. To be clear, in many hospitals the hospitalists are reasonably content with using the EHR, but they experience ongoing frustration and low morale resulting from nonclinical work other doctors pressure them to take over.
Observation status. Many hospitals began classifying a larger portion of patients as observation status over the last few years; at the same time, patients and families have become more aware of how much of a disadvantage this is. In many cases, it is the hospitalist who takes the brunt of patient and family frustration. This can get awfully stressful and frustrating, and I think it is a contributor to allegations of malpractice.
Budgetary stress. Ever since SHM began collecting survey data in the late 1990s, the financial support hospitals have been providing to hospitalists has increased dramatically. The most recent State of Hospital Medicine report, published in 2104, showed median support provided by hospitals of $156,063 per FTE hospitalist, per year. Some hospitals have begun to resist providing more support, and this translates into stress and lower morale for hospitalists. This is far from a universal issue, but it does lead to lower morale for hospitalists who face it.
Many other factors may be contributing to a national decline in morale, but I think these are some of the most important.
What Can Be Done?
Some hospitalist groups have great morale now and don’t need to do much of anything right now, but some groups should think about a deliberate strategy to improve it.
Sadly, there isn’t a prescription that is sure to work. But there are some things you can try.
Self-care. The field of palliative care has thought a lot about caring for caregivers, and hospitalist groups might want to adopt some of their practices. Search the Internet on “self-care” + “palliative care,” and you’ll find a lot of interesting things. The group I’m part of launched a deliberate program of professionally led and facilitated hospitalist self-care, with high hopes that included mindful meditation, among other things. As soon as we had designed our program, the Mayo Clinic published their favorable experience with a program that was very similar to what we had planned, and I thought we would see similar benefits.3
But, while all who attended the sessions thought they were valuable, attendance was so poor that we ended up cancelling the program. The hospitalists were interested in attending but were either on service and busy seeing patients, or were off and didn’t want to drive in to work solely for the purpose of reducing work stress.
I’m convinced a self-care program is valuable but very tricky to schedule effectively. Maybe others have come up with effective ways of overcoming this problem.
Social connections. Some hospitalist groups seem to have little social and personal connection to other physicians and hospital leaders. I think this results in lower hospitalist morale and tends to be self-reinforcing. If you’re in such a group, you and your hospitalist colleagues should deliberately seek better relationships with other doctors and hospital administrative leaders. Ensure that you visit with others at lunch, talk with them at committee meetings, ask about their vacation and personal activities, and pursue activities with them outside of work.
When these sorts of social connections are strong, work is far more satisfying and you’re much more likely to be treated as a peer by other doctors. I think this is really important and shouldn’t be overlooked if your group is suffering from low morale.
Adaptive work. Lastly, you might want to approach changes to your work and morale as “adaptive work,” rather than “technical work.” Space doesn’t permit a description of these, but it is worth reading about how they differ. Many groups will find value in reframing their approach to aspects of work they don’t like as adaptive work.
References
- Hinami K, Whelan CT, Wolosin RJ, Miller JA, Wetterneck TB. Worklife and satisfaction of hospitalists: toward flourishing careers. J Gen Intern Med. 2012;27(1):28-36.
- Hoff TH, Whitcomb WF, Williams K, Nelson JR, Cheesman RA. Characteristics and work experiences of hospitalists in the United States. Arch Intern Med. 2001;161(6):851-858.
- West CP, Dyrbye LN, Rabatin JT, et al. Intervention to promote physician well-being, job satisfaction, and professionalism: a randomized clinical trial. JAMA Intern Med. 2014;174(4):527-533.
Using quotes to ensure that the results were only those that include the two words adjacent to one another, rather than separated, I entered the following phrases into my Google search engine:
- “hospitalist burnout” = 1,580 results
- “hospitalist morale” = 208 results
- “hospitalist well-being” = 0 results
I think the number of results suggests the level of interest in each topic and, if that is the case, clearly thinking about how hospitalists are doing in their careers is more commonly done through the paradigm of burnout than the other two terms. (Of course, there may be other terms that I didn’t consider.) In fact, there have been a handful of published studies of hospitalist burnout and job satisfaction.1,2
Those studies generally have shown both reasonably high levels of job satisfaction and troubling levels of burnout.
But I’ve been thinking about hospitalist morale for a while. I think morale is reasonably distinct from both burnout and job satisfaction.
Causes of a National Decline in Hospitalist Morale
I think hospitalist morale has declined some over the past two or three years across the country. This observation is meaningful because it comes from my experience working with a lot of hospitalist groups coast to coast. But I’m the first to admit it is just anecdotal and is subject to my own biases.
I can think of several things contributing to a decline in morale.
EHR adoption. Near the top of the list is the adoption of EHRs in many hospitals, which typically leads doctors in other specialties to seek hospitalist assistance with EHR-related tasks (e.g. medicine reconciliation and order writing) even in cases where there is little or no clinical reason for hospitalist involvement. Lots of hospitalists complain about this. To be clear, in many hospitals the hospitalists are reasonably content with using the EHR, but they experience ongoing frustration and low morale resulting from nonclinical work other doctors pressure them to take over.
Observation status. Many hospitals began classifying a larger portion of patients as observation status over the last few years; at the same time, patients and families have become more aware of how much of a disadvantage this is. In many cases, it is the hospitalist who takes the brunt of patient and family frustration. This can get awfully stressful and frustrating, and I think it is a contributor to allegations of malpractice.
Budgetary stress. Ever since SHM began collecting survey data in the late 1990s, the financial support hospitals have been providing to hospitalists has increased dramatically. The most recent State of Hospital Medicine report, published in 2104, showed median support provided by hospitals of $156,063 per FTE hospitalist, per year. Some hospitals have begun to resist providing more support, and this translates into stress and lower morale for hospitalists. This is far from a universal issue, but it does lead to lower morale for hospitalists who face it.
Many other factors may be contributing to a national decline in morale, but I think these are some of the most important.
What Can Be Done?
Some hospitalist groups have great morale now and don’t need to do much of anything right now, but some groups should think about a deliberate strategy to improve it.
Sadly, there isn’t a prescription that is sure to work. But there are some things you can try.
Self-care. The field of palliative care has thought a lot about caring for caregivers, and hospitalist groups might want to adopt some of their practices. Search the Internet on “self-care” + “palliative care,” and you’ll find a lot of interesting things. The group I’m part of launched a deliberate program of professionally led and facilitated hospitalist self-care, with high hopes that included mindful meditation, among other things. As soon as we had designed our program, the Mayo Clinic published their favorable experience with a program that was very similar to what we had planned, and I thought we would see similar benefits.3
But, while all who attended the sessions thought they were valuable, attendance was so poor that we ended up cancelling the program. The hospitalists were interested in attending but were either on service and busy seeing patients, or were off and didn’t want to drive in to work solely for the purpose of reducing work stress.
I’m convinced a self-care program is valuable but very tricky to schedule effectively. Maybe others have come up with effective ways of overcoming this problem.
Social connections. Some hospitalist groups seem to have little social and personal connection to other physicians and hospital leaders. I think this results in lower hospitalist morale and tends to be self-reinforcing. If you’re in such a group, you and your hospitalist colleagues should deliberately seek better relationships with other doctors and hospital administrative leaders. Ensure that you visit with others at lunch, talk with them at committee meetings, ask about their vacation and personal activities, and pursue activities with them outside of work.
When these sorts of social connections are strong, work is far more satisfying and you’re much more likely to be treated as a peer by other doctors. I think this is really important and shouldn’t be overlooked if your group is suffering from low morale.
Adaptive work. Lastly, you might want to approach changes to your work and morale as “adaptive work,” rather than “technical work.” Space doesn’t permit a description of these, but it is worth reading about how they differ. Many groups will find value in reframing their approach to aspects of work they don’t like as adaptive work.
References
- Hinami K, Whelan CT, Wolosin RJ, Miller JA, Wetterneck TB. Worklife and satisfaction of hospitalists: toward flourishing careers. J Gen Intern Med. 2012;27(1):28-36.
- Hoff TH, Whitcomb WF, Williams K, Nelson JR, Cheesman RA. Characteristics and work experiences of hospitalists in the United States. Arch Intern Med. 2001;161(6):851-858.
- West CP, Dyrbye LN, Rabatin JT, et al. Intervention to promote physician well-being, job satisfaction, and professionalism: a randomized clinical trial. JAMA Intern Med. 2014;174(4):527-533.
Using quotes to ensure that the results were only those that include the two words adjacent to one another, rather than separated, I entered the following phrases into my Google search engine:
- “hospitalist burnout” = 1,580 results
- “hospitalist morale” = 208 results
- “hospitalist well-being” = 0 results
I think the number of results suggests the level of interest in each topic and, if that is the case, clearly thinking about how hospitalists are doing in their careers is more commonly done through the paradigm of burnout than the other two terms. (Of course, there may be other terms that I didn’t consider.) In fact, there have been a handful of published studies of hospitalist burnout and job satisfaction.1,2
Those studies generally have shown both reasonably high levels of job satisfaction and troubling levels of burnout.
But I’ve been thinking about hospitalist morale for a while. I think morale is reasonably distinct from both burnout and job satisfaction.
Causes of a National Decline in Hospitalist Morale
I think hospitalist morale has declined some over the past two or three years across the country. This observation is meaningful because it comes from my experience working with a lot of hospitalist groups coast to coast. But I’m the first to admit it is just anecdotal and is subject to my own biases.
I can think of several things contributing to a decline in morale.
EHR adoption. Near the top of the list is the adoption of EHRs in many hospitals, which typically leads doctors in other specialties to seek hospitalist assistance with EHR-related tasks (e.g. medicine reconciliation and order writing) even in cases where there is little or no clinical reason for hospitalist involvement. Lots of hospitalists complain about this. To be clear, in many hospitals the hospitalists are reasonably content with using the EHR, but they experience ongoing frustration and low morale resulting from nonclinical work other doctors pressure them to take over.
Observation status. Many hospitals began classifying a larger portion of patients as observation status over the last few years; at the same time, patients and families have become more aware of how much of a disadvantage this is. In many cases, it is the hospitalist who takes the brunt of patient and family frustration. This can get awfully stressful and frustrating, and I think it is a contributor to allegations of malpractice.
Budgetary stress. Ever since SHM began collecting survey data in the late 1990s, the financial support hospitals have been providing to hospitalists has increased dramatically. The most recent State of Hospital Medicine report, published in 2104, showed median support provided by hospitals of $156,063 per FTE hospitalist, per year. Some hospitals have begun to resist providing more support, and this translates into stress and lower morale for hospitalists. This is far from a universal issue, but it does lead to lower morale for hospitalists who face it.
Many other factors may be contributing to a national decline in morale, but I think these are some of the most important.
What Can Be Done?
Some hospitalist groups have great morale now and don’t need to do much of anything right now, but some groups should think about a deliberate strategy to improve it.
Sadly, there isn’t a prescription that is sure to work. But there are some things you can try.
Self-care. The field of palliative care has thought a lot about caring for caregivers, and hospitalist groups might want to adopt some of their practices. Search the Internet on “self-care” + “palliative care,” and you’ll find a lot of interesting things. The group I’m part of launched a deliberate program of professionally led and facilitated hospitalist self-care, with high hopes that included mindful meditation, among other things. As soon as we had designed our program, the Mayo Clinic published their favorable experience with a program that was very similar to what we had planned, and I thought we would see similar benefits.3
But, while all who attended the sessions thought they were valuable, attendance was so poor that we ended up cancelling the program. The hospitalists were interested in attending but were either on service and busy seeing patients, or were off and didn’t want to drive in to work solely for the purpose of reducing work stress.
I’m convinced a self-care program is valuable but very tricky to schedule effectively. Maybe others have come up with effective ways of overcoming this problem.
Social connections. Some hospitalist groups seem to have little social and personal connection to other physicians and hospital leaders. I think this results in lower hospitalist morale and tends to be self-reinforcing. If you’re in such a group, you and your hospitalist colleagues should deliberately seek better relationships with other doctors and hospital administrative leaders. Ensure that you visit with others at lunch, talk with them at committee meetings, ask about their vacation and personal activities, and pursue activities with them outside of work.
When these sorts of social connections are strong, work is far more satisfying and you’re much more likely to be treated as a peer by other doctors. I think this is really important and shouldn’t be overlooked if your group is suffering from low morale.
Adaptive work. Lastly, you might want to approach changes to your work and morale as “adaptive work,” rather than “technical work.” Space doesn’t permit a description of these, but it is worth reading about how they differ. Many groups will find value in reframing their approach to aspects of work they don’t like as adaptive work.
References
- Hinami K, Whelan CT, Wolosin RJ, Miller JA, Wetterneck TB. Worklife and satisfaction of hospitalists: toward flourishing careers. J Gen Intern Med. 2012;27(1):28-36.
- Hoff TH, Whitcomb WF, Williams K, Nelson JR, Cheesman RA. Characteristics and work experiences of hospitalists in the United States. Arch Intern Med. 2001;161(6):851-858.
- West CP, Dyrbye LN, Rabatin JT, et al. Intervention to promote physician well-being, job satisfaction, and professionalism: a randomized clinical trial. JAMA Intern Med. 2014;174(4):527-533.
Corticosteroids Show Benefit in Community-Acquired Pneumonia
Clinical question: Does corticosteroid treatment shorten systemic illness in patients admitted to the hospital for community-acquired pneumonia (CAP)?
Background: Pneumonia is the third-leading cause of death worldwide. Studies have yielded conflicting data about the benefit of adding systemic corticosteroids for treatment of CAP.
Study design: Double-blind, multicenter, randomized, placebo-controlled trial.
Setting: Seven tertiary-care hospitals in Switzerland.
Synopsis: A group of 784 patients hospitalized for CAP were randomized to receive either oral prednisone 50 mg daily for seven days or placebo, with the primary endpoint being time to stable vital signs. The intention-to-treat analysis found that the median time to clinical stability was 1.4 days earlier in the prednisone group (hazard ratio 1.33; 95% CI, 1.15–1.50, P <0.0001) and that length of stay and IV antibiotics were reduced by one day; this effect was valid across all PSI classes and was not dependent on age. Pneumonia-associated complications in the two groups did not differ at 30 days, though the prednisone group had a higher incidence of hyperglycemia requiring insulin. Because all study locations were in a single, fairly homogenous northern European country, care should be taken when hospitalists apply these findings to their patient population, and the risks of hyperglycemia requiring insulin should be taken into consideration.
Bottom line: Systemic steroids may reduce the time to clinical stability in patients with CAP.
Citation: Blum CA, Nigro N, Briel M, et al. Adjunct prednisone therapy for patients with community-acquired pneumonia: a multicentre, double-blind, randomised, placebo-controlled trial. Lancet. 2015;385(9977):1511–1518.
Clinical question: Does corticosteroid treatment shorten systemic illness in patients admitted to the hospital for community-acquired pneumonia (CAP)?
Background: Pneumonia is the third-leading cause of death worldwide. Studies have yielded conflicting data about the benefit of adding systemic corticosteroids for treatment of CAP.
Study design: Double-blind, multicenter, randomized, placebo-controlled trial.
Setting: Seven tertiary-care hospitals in Switzerland.
Synopsis: A group of 784 patients hospitalized for CAP were randomized to receive either oral prednisone 50 mg daily for seven days or placebo, with the primary endpoint being time to stable vital signs. The intention-to-treat analysis found that the median time to clinical stability was 1.4 days earlier in the prednisone group (hazard ratio 1.33; 95% CI, 1.15–1.50, P <0.0001) and that length of stay and IV antibiotics were reduced by one day; this effect was valid across all PSI classes and was not dependent on age. Pneumonia-associated complications in the two groups did not differ at 30 days, though the prednisone group had a higher incidence of hyperglycemia requiring insulin. Because all study locations were in a single, fairly homogenous northern European country, care should be taken when hospitalists apply these findings to their patient population, and the risks of hyperglycemia requiring insulin should be taken into consideration.
Bottom line: Systemic steroids may reduce the time to clinical stability in patients with CAP.
Citation: Blum CA, Nigro N, Briel M, et al. Adjunct prednisone therapy for patients with community-acquired pneumonia: a multicentre, double-blind, randomised, placebo-controlled trial. Lancet. 2015;385(9977):1511–1518.
Clinical question: Does corticosteroid treatment shorten systemic illness in patients admitted to the hospital for community-acquired pneumonia (CAP)?
Background: Pneumonia is the third-leading cause of death worldwide. Studies have yielded conflicting data about the benefit of adding systemic corticosteroids for treatment of CAP.
Study design: Double-blind, multicenter, randomized, placebo-controlled trial.
Setting: Seven tertiary-care hospitals in Switzerland.
Synopsis: A group of 784 patients hospitalized for CAP were randomized to receive either oral prednisone 50 mg daily for seven days or placebo, with the primary endpoint being time to stable vital signs. The intention-to-treat analysis found that the median time to clinical stability was 1.4 days earlier in the prednisone group (hazard ratio 1.33; 95% CI, 1.15–1.50, P <0.0001) and that length of stay and IV antibiotics were reduced by one day; this effect was valid across all PSI classes and was not dependent on age. Pneumonia-associated complications in the two groups did not differ at 30 days, though the prednisone group had a higher incidence of hyperglycemia requiring insulin. Because all study locations were in a single, fairly homogenous northern European country, care should be taken when hospitalists apply these findings to their patient population, and the risks of hyperglycemia requiring insulin should be taken into consideration.
Bottom line: Systemic steroids may reduce the time to clinical stability in patients with CAP.
Citation: Blum CA, Nigro N, Briel M, et al. Adjunct prednisone therapy for patients with community-acquired pneumonia: a multicentre, double-blind, randomised, placebo-controlled trial. Lancet. 2015;385(9977):1511–1518.
Infection, Acute Kidney Injury Raise 30-Day Readmission Risk for Sepsis Survivors
Nearly one-third of hospitalized patients who survive severe sepsis or septic shock require readmission within 30 days, according to a new report in the Journal of Hospital Medicine. Between 660,000 and 750,000 sepsis hospitalizations occur annually, with the direct costs surpassing $24 billion, the paper notes.
The study, which examined 1697 sepsis survivors from 2008 to 2012, links several clinical factors with increased 30-day readmission risk, including infection with Bacteroides spp and extended-spectrum beta-lactamases organisms and puts sepsis survivors with mild-to-moderate acute kidney injury (AKI) at nearly double the risk of readmission.
Study lead author Marya Zilberberg, MD, MPH, notes that efforts to reduce AKI in sepsis survivors might affect patient outcomes but that more research needs to be done to help decrease readmission rates.
“The hypothesis that reducing the occurrence of AKI would in turn reduce the risk of a 30-day hospitalization needs to be validated,” Dr. Zilberberg writes in an email to The Hospitalist. “Furthermore, it is a difficult goal among the critically ill. So, what this means to me is … this quality metric may be yet another that is putting the cart (the metric) before the horse (evidence to support its use).”
Dr. Zilberberg, founder and president of EviMed Research Group, LLC, an evidence-based medicine and outcomes research firm based in Goshen, Mass., says the study’s results were not completely unexpected as resistant infections are associated with worsening of all outcomes, and “we just showed that 30-day readmission was not immune to that,” she notes.
“We are not sure what effective strategies [there] may be to achieve this goal,” she notes. “In general, delivery of best-known care is the best that can be done. The most that can be said from our study is that antimicrobial resistance is bad even vis-à-vis this outcome, so reducing the burden of antimicrobial resistance, in addition to AKI prevention, is a strategy that might impact this outcome, along with many others.”
Visit our website for more information on sepsis and HM.
Nearly one-third of hospitalized patients who survive severe sepsis or septic shock require readmission within 30 days, according to a new report in the Journal of Hospital Medicine. Between 660,000 and 750,000 sepsis hospitalizations occur annually, with the direct costs surpassing $24 billion, the paper notes.
The study, which examined 1697 sepsis survivors from 2008 to 2012, links several clinical factors with increased 30-day readmission risk, including infection with Bacteroides spp and extended-spectrum beta-lactamases organisms and puts sepsis survivors with mild-to-moderate acute kidney injury (AKI) at nearly double the risk of readmission.
Study lead author Marya Zilberberg, MD, MPH, notes that efforts to reduce AKI in sepsis survivors might affect patient outcomes but that more research needs to be done to help decrease readmission rates.
“The hypothesis that reducing the occurrence of AKI would in turn reduce the risk of a 30-day hospitalization needs to be validated,” Dr. Zilberberg writes in an email to The Hospitalist. “Furthermore, it is a difficult goal among the critically ill. So, what this means to me is … this quality metric may be yet another that is putting the cart (the metric) before the horse (evidence to support its use).”
Dr. Zilberberg, founder and president of EviMed Research Group, LLC, an evidence-based medicine and outcomes research firm based in Goshen, Mass., says the study’s results were not completely unexpected as resistant infections are associated with worsening of all outcomes, and “we just showed that 30-day readmission was not immune to that,” she notes.
“We are not sure what effective strategies [there] may be to achieve this goal,” she notes. “In general, delivery of best-known care is the best that can be done. The most that can be said from our study is that antimicrobial resistance is bad even vis-à-vis this outcome, so reducing the burden of antimicrobial resistance, in addition to AKI prevention, is a strategy that might impact this outcome, along with many others.”
Visit our website for more information on sepsis and HM.
Nearly one-third of hospitalized patients who survive severe sepsis or septic shock require readmission within 30 days, according to a new report in the Journal of Hospital Medicine. Between 660,000 and 750,000 sepsis hospitalizations occur annually, with the direct costs surpassing $24 billion, the paper notes.
The study, which examined 1697 sepsis survivors from 2008 to 2012, links several clinical factors with increased 30-day readmission risk, including infection with Bacteroides spp and extended-spectrum beta-lactamases organisms and puts sepsis survivors with mild-to-moderate acute kidney injury (AKI) at nearly double the risk of readmission.
Study lead author Marya Zilberberg, MD, MPH, notes that efforts to reduce AKI in sepsis survivors might affect patient outcomes but that more research needs to be done to help decrease readmission rates.
“The hypothesis that reducing the occurrence of AKI would in turn reduce the risk of a 30-day hospitalization needs to be validated,” Dr. Zilberberg writes in an email to The Hospitalist. “Furthermore, it is a difficult goal among the critically ill. So, what this means to me is … this quality metric may be yet another that is putting the cart (the metric) before the horse (evidence to support its use).”
Dr. Zilberberg, founder and president of EviMed Research Group, LLC, an evidence-based medicine and outcomes research firm based in Goshen, Mass., says the study’s results were not completely unexpected as resistant infections are associated with worsening of all outcomes, and “we just showed that 30-day readmission was not immune to that,” she notes.
“We are not sure what effective strategies [there] may be to achieve this goal,” she notes. “In general, delivery of best-known care is the best that can be done. The most that can be said from our study is that antimicrobial resistance is bad even vis-à-vis this outcome, so reducing the burden of antimicrobial resistance, in addition to AKI prevention, is a strategy that might impact this outcome, along with many others.”
Visit our website for more information on sepsis and HM.
Medicare Rule May Needlessly Extend Hospital Stay
(Reuters Health) - A decades old Medicare rule requiring a three-day hospital stay before patients can transfer to skilled nursing facilities may needlessly prolong hospitalizations, a study suggests.
Researchers compared the average time patients were hospitalized between 2006 and 2010 in privately administered Medicare Advantage health plans that either stuck to this rule or allowed people to transfer to skilled nursing facilities sooner.
Lengths of hospital stays increased with the rule in place and declined when it was waived, the study found.
"The three-day stay rule may inappropriately lengthen the time spent in a hospital for patients who could be transferred to a skilled nursing facility earlier," senior author Dr. Amal Trivedi, a health policy researcher at Brown University in Providence, Rhode Island, said by email.
This minimum-stay rule dates back to the 1960s, when patients typically remained in the hospital for nearly two weeks, and three days was the minimum time needed to evaluate them and plan their post-hospital care, Trivedi and colleagues note in the journal Health Affairs for August.
Since then, typical stays have shortened, and skilled nursing facilities have become an increasingly common treatment setting for patients with complex medical problems who no longer require acute inpatient care.
To see how the three-day minimum stay requirement might impact hospitalization, researchers compared the typical number of hospital days for nearly 141,000 patients in 14 Medicare Advantage plans that upheld the rule and for nearly 117,000 people in 14 similar plans that waived it.
The people enrolled in plans that waived the rule were typically younger, poorer and less likely to be white.
For plans that waived the rule, 23.5% of hospitalized patients were admitted to skilled nursing facilities in the year before the rule was eliminated, compared with 25.7% in the year after it went away.
Plans that kept the rule saw a similar gain, from 22.8% to 26.3%.
But the average length of hospital stays for patients in plans that waived the three-day rule declined from 6.9 days to 6.7 days, compared with an increase from 6.1 days to 6.6 days in plans that kept the requirement in place.
Overall, the average reduction in hospital stays was 0.7 days with the rule elimination, translating into approximately $1,500 in savings for every admission that ended with a transfer to a skilled nursing facility, the researchers estimated.
One limitation of the study, however, is that it looked at hospital days over the entire year, rather then the number of days for each stay, the researchers acknowledge. It's also possible that the cost savings wouldn't be the same for people with traditional fee-for-service Medicare or other plans unlike the ones in the study.
Even so, as hospital stays become shorter and patients with complicated illnesses are treated in other settings, it makes sense to revisit whether the three days is the right cutoff to identify people who can appropriately transfer to a skilled nursing facility, said David Grabowski, a health policy researcher at Harvard Medical School in Boston.
Certain patients may also benefit from leaving the hospital sooner, because longer stays can increase their risk of infections and make it less likely that they get out of bed for physical activity that can aid recovery, Grabowski, who wasn't involved in the study, said by email.
"Some individuals with short hospital stays may be inappropriately excluded from skilled nursing facility care under the current system," he said. "Moreover, this rule has led to some unintended consequences like the growth in observational stays."
"There really aren't many benefits to staying beyond medical necessity," Grabowski added.
(Reuters Health) - A decades old Medicare rule requiring a three-day hospital stay before patients can transfer to skilled nursing facilities may needlessly prolong hospitalizations, a study suggests.
Researchers compared the average time patients were hospitalized between 2006 and 2010 in privately administered Medicare Advantage health plans that either stuck to this rule or allowed people to transfer to skilled nursing facilities sooner.
Lengths of hospital stays increased with the rule in place and declined when it was waived, the study found.
"The three-day stay rule may inappropriately lengthen the time spent in a hospital for patients who could be transferred to a skilled nursing facility earlier," senior author Dr. Amal Trivedi, a health policy researcher at Brown University in Providence, Rhode Island, said by email.
This minimum-stay rule dates back to the 1960s, when patients typically remained in the hospital for nearly two weeks, and three days was the minimum time needed to evaluate them and plan their post-hospital care, Trivedi and colleagues note in the journal Health Affairs for August.
Since then, typical stays have shortened, and skilled nursing facilities have become an increasingly common treatment setting for patients with complex medical problems who no longer require acute inpatient care.
To see how the three-day minimum stay requirement might impact hospitalization, researchers compared the typical number of hospital days for nearly 141,000 patients in 14 Medicare Advantage plans that upheld the rule and for nearly 117,000 people in 14 similar plans that waived it.
The people enrolled in plans that waived the rule were typically younger, poorer and less likely to be white.
For plans that waived the rule, 23.5% of hospitalized patients were admitted to skilled nursing facilities in the year before the rule was eliminated, compared with 25.7% in the year after it went away.
Plans that kept the rule saw a similar gain, from 22.8% to 26.3%.
But the average length of hospital stays for patients in plans that waived the three-day rule declined from 6.9 days to 6.7 days, compared with an increase from 6.1 days to 6.6 days in plans that kept the requirement in place.
Overall, the average reduction in hospital stays was 0.7 days with the rule elimination, translating into approximately $1,500 in savings for every admission that ended with a transfer to a skilled nursing facility, the researchers estimated.
One limitation of the study, however, is that it looked at hospital days over the entire year, rather then the number of days for each stay, the researchers acknowledge. It's also possible that the cost savings wouldn't be the same for people with traditional fee-for-service Medicare or other plans unlike the ones in the study.
Even so, as hospital stays become shorter and patients with complicated illnesses are treated in other settings, it makes sense to revisit whether the three days is the right cutoff to identify people who can appropriately transfer to a skilled nursing facility, said David Grabowski, a health policy researcher at Harvard Medical School in Boston.
Certain patients may also benefit from leaving the hospital sooner, because longer stays can increase their risk of infections and make it less likely that they get out of bed for physical activity that can aid recovery, Grabowski, who wasn't involved in the study, said by email.
"Some individuals with short hospital stays may be inappropriately excluded from skilled nursing facility care under the current system," he said. "Moreover, this rule has led to some unintended consequences like the growth in observational stays."
"There really aren't many benefits to staying beyond medical necessity," Grabowski added.
(Reuters Health) - A decades old Medicare rule requiring a three-day hospital stay before patients can transfer to skilled nursing facilities may needlessly prolong hospitalizations, a study suggests.
Researchers compared the average time patients were hospitalized between 2006 and 2010 in privately administered Medicare Advantage health plans that either stuck to this rule or allowed people to transfer to skilled nursing facilities sooner.
Lengths of hospital stays increased with the rule in place and declined when it was waived, the study found.
"The three-day stay rule may inappropriately lengthen the time spent in a hospital for patients who could be transferred to a skilled nursing facility earlier," senior author Dr. Amal Trivedi, a health policy researcher at Brown University in Providence, Rhode Island, said by email.
This minimum-stay rule dates back to the 1960s, when patients typically remained in the hospital for nearly two weeks, and three days was the minimum time needed to evaluate them and plan their post-hospital care, Trivedi and colleagues note in the journal Health Affairs for August.
Since then, typical stays have shortened, and skilled nursing facilities have become an increasingly common treatment setting for patients with complex medical problems who no longer require acute inpatient care.
To see how the three-day minimum stay requirement might impact hospitalization, researchers compared the typical number of hospital days for nearly 141,000 patients in 14 Medicare Advantage plans that upheld the rule and for nearly 117,000 people in 14 similar plans that waived it.
The people enrolled in plans that waived the rule were typically younger, poorer and less likely to be white.
For plans that waived the rule, 23.5% of hospitalized patients were admitted to skilled nursing facilities in the year before the rule was eliminated, compared with 25.7% in the year after it went away.
Plans that kept the rule saw a similar gain, from 22.8% to 26.3%.
But the average length of hospital stays for patients in plans that waived the three-day rule declined from 6.9 days to 6.7 days, compared with an increase from 6.1 days to 6.6 days in plans that kept the requirement in place.
Overall, the average reduction in hospital stays was 0.7 days with the rule elimination, translating into approximately $1,500 in savings for every admission that ended with a transfer to a skilled nursing facility, the researchers estimated.
One limitation of the study, however, is that it looked at hospital days over the entire year, rather then the number of days for each stay, the researchers acknowledge. It's also possible that the cost savings wouldn't be the same for people with traditional fee-for-service Medicare or other plans unlike the ones in the study.
Even so, as hospital stays become shorter and patients with complicated illnesses are treated in other settings, it makes sense to revisit whether the three days is the right cutoff to identify people who can appropriately transfer to a skilled nursing facility, said David Grabowski, a health policy researcher at Harvard Medical School in Boston.
Certain patients may also benefit from leaving the hospital sooner, because longer stays can increase their risk of infections and make it less likely that they get out of bed for physical activity that can aid recovery, Grabowski, who wasn't involved in the study, said by email.
"Some individuals with short hospital stays may be inappropriately excluded from skilled nursing facility care under the current system," he said. "Moreover, this rule has led to some unintended consequences like the growth in observational stays."
"There really aren't many benefits to staying beyond medical necessity," Grabowski added.
Better Catheter-Directed Thrombolysis Outcomes at Higher-Volume Institutions
NEW YORK - In-hospital mortality and bleeding rates after catheter-directed thrombolysis (CDT) of lower extremity proximal deep vein thrombosis are lower in institutions that perform more procedures than in those with fewer procedures, according to a new study.
"As utilization of CDT continues to increase, we propose that institutions follow a standardized CDT protocol that includes careful patient selection as well as patient monitoring," Dr. Riyaz Bashir from Temple University School of Medicine in Philadelphia, Pennsylvania, told Reuters Health by email. "In addition, establishment of centers of excellence in treating venous thromboembolic disease may provide the necessary framework within which bleeding risk to the patient can be minimized."
CDT is increasingly favored over anticoagulation for patients with lower extremity proximal deep vein thrombosis (LE-DVT), but it has been associated with increased bleeding rates and procedure-related complications, Dr. Bashir and colleagues note in Circulation, online July 21.
In light of literature implicating institutional volume as a significant factor in patient outcomes, the team used the Nationwide Inpatient Sample database to investigate the relationship between annual institutional procedure volume and adverse in-hospital patient outcomes in patients receiving CDT for acute proximal LE-DVT.
Just over half the 3,649 procedures were performed at high-volume centers (six or more procedures per year), with the remainder (43%) done at low-volume centers (less than six procedures per year).
In a propensity-matched comparison of 1,310 patients from each group, in-hospital mortality was significantly lower at high-volume centers than at low-volume centers (0.6% vs. 1.5%, p=0.04), the researchers found.
Intracranial hemorrhage rates tended to be lower at high-volume centers (0.4% vs. 1.0%, p=0.07), while inferior vena cava filter placement rates were significantly higher at high-volume centers (37.0% vs. 32.8%; p=0.03).
Institutional volume did not influence blood transfusion, GI bleeding, or pulmonary embolism rates or hospital length of stay. Median hospital charges were higher at high-volume centers ($75,870) than at low-volume centers ($65,500).
At low-volume centers, outcomes tended to be worse for CDT plus anticoagulation than for anticoagulation alone, whereas outcomes were similar for CDT plus anticoagulation and for anticoagulation alone at high-volume centers.
On multiple regression analysis, there was a significant inverse relationship between institutional volume and in-hospital mortality.
"Our observation that the major safety outcomes (death and intracranial hemorrhage) were not significantly different between patients undergoing CDT as compared to patients undergoing anticoagulation therapy alone at high volume centers suggests that these complications can be minimized," Dr. Bashir concluded. "Patients with leg DVT - especially young patients - should feel comfortable considering clot removal, particularly at a high volume center, as a viable option to prevent post-thrombotic syndrome."
NEW YORK - In-hospital mortality and bleeding rates after catheter-directed thrombolysis (CDT) of lower extremity proximal deep vein thrombosis are lower in institutions that perform more procedures than in those with fewer procedures, according to a new study.
"As utilization of CDT continues to increase, we propose that institutions follow a standardized CDT protocol that includes careful patient selection as well as patient monitoring," Dr. Riyaz Bashir from Temple University School of Medicine in Philadelphia, Pennsylvania, told Reuters Health by email. "In addition, establishment of centers of excellence in treating venous thromboembolic disease may provide the necessary framework within which bleeding risk to the patient can be minimized."
CDT is increasingly favored over anticoagulation for patients with lower extremity proximal deep vein thrombosis (LE-DVT), but it has been associated with increased bleeding rates and procedure-related complications, Dr. Bashir and colleagues note in Circulation, online July 21.
In light of literature implicating institutional volume as a significant factor in patient outcomes, the team used the Nationwide Inpatient Sample database to investigate the relationship between annual institutional procedure volume and adverse in-hospital patient outcomes in patients receiving CDT for acute proximal LE-DVT.
Just over half the 3,649 procedures were performed at high-volume centers (six or more procedures per year), with the remainder (43%) done at low-volume centers (less than six procedures per year).
In a propensity-matched comparison of 1,310 patients from each group, in-hospital mortality was significantly lower at high-volume centers than at low-volume centers (0.6% vs. 1.5%, p=0.04), the researchers found.
Intracranial hemorrhage rates tended to be lower at high-volume centers (0.4% vs. 1.0%, p=0.07), while inferior vena cava filter placement rates were significantly higher at high-volume centers (37.0% vs. 32.8%; p=0.03).
Institutional volume did not influence blood transfusion, GI bleeding, or pulmonary embolism rates or hospital length of stay. Median hospital charges were higher at high-volume centers ($75,870) than at low-volume centers ($65,500).
At low-volume centers, outcomes tended to be worse for CDT plus anticoagulation than for anticoagulation alone, whereas outcomes were similar for CDT plus anticoagulation and for anticoagulation alone at high-volume centers.
On multiple regression analysis, there was a significant inverse relationship between institutional volume and in-hospital mortality.
"Our observation that the major safety outcomes (death and intracranial hemorrhage) were not significantly different between patients undergoing CDT as compared to patients undergoing anticoagulation therapy alone at high volume centers suggests that these complications can be minimized," Dr. Bashir concluded. "Patients with leg DVT - especially young patients - should feel comfortable considering clot removal, particularly at a high volume center, as a viable option to prevent post-thrombotic syndrome."
NEW YORK - In-hospital mortality and bleeding rates after catheter-directed thrombolysis (CDT) of lower extremity proximal deep vein thrombosis are lower in institutions that perform more procedures than in those with fewer procedures, according to a new study.
"As utilization of CDT continues to increase, we propose that institutions follow a standardized CDT protocol that includes careful patient selection as well as patient monitoring," Dr. Riyaz Bashir from Temple University School of Medicine in Philadelphia, Pennsylvania, told Reuters Health by email. "In addition, establishment of centers of excellence in treating venous thromboembolic disease may provide the necessary framework within which bleeding risk to the patient can be minimized."
CDT is increasingly favored over anticoagulation for patients with lower extremity proximal deep vein thrombosis (LE-DVT), but it has been associated with increased bleeding rates and procedure-related complications, Dr. Bashir and colleagues note in Circulation, online July 21.
In light of literature implicating institutional volume as a significant factor in patient outcomes, the team used the Nationwide Inpatient Sample database to investigate the relationship between annual institutional procedure volume and adverse in-hospital patient outcomes in patients receiving CDT for acute proximal LE-DVT.
Just over half the 3,649 procedures were performed at high-volume centers (six or more procedures per year), with the remainder (43%) done at low-volume centers (less than six procedures per year).
In a propensity-matched comparison of 1,310 patients from each group, in-hospital mortality was significantly lower at high-volume centers than at low-volume centers (0.6% vs. 1.5%, p=0.04), the researchers found.
Intracranial hemorrhage rates tended to be lower at high-volume centers (0.4% vs. 1.0%, p=0.07), while inferior vena cava filter placement rates were significantly higher at high-volume centers (37.0% vs. 32.8%; p=0.03).
Institutional volume did not influence blood transfusion, GI bleeding, or pulmonary embolism rates or hospital length of stay. Median hospital charges were higher at high-volume centers ($75,870) than at low-volume centers ($65,500).
At low-volume centers, outcomes tended to be worse for CDT plus anticoagulation than for anticoagulation alone, whereas outcomes were similar for CDT plus anticoagulation and for anticoagulation alone at high-volume centers.
On multiple regression analysis, there was a significant inverse relationship between institutional volume and in-hospital mortality.
"Our observation that the major safety outcomes (death and intracranial hemorrhage) were not significantly different between patients undergoing CDT as compared to patients undergoing anticoagulation therapy alone at high volume centers suggests that these complications can be minimized," Dr. Bashir concluded. "Patients with leg DVT - especially young patients - should feel comfortable considering clot removal, particularly at a high volume center, as a viable option to prevent post-thrombotic syndrome."
Inflammation Contributes to Effect of Diabetes on Brain
NEW YORK - Inflammation may contribute to impaired cerebral vasoregulation in type 2 diabetes, research suggests.
In a two-year study, participants with type 2 diabetes experienced diminished regional and global vasoreactivity in the brain, as well as a decline in cognitive function and the ability to perform daily tasks.
Higher blood levels of inflammatory markers were correlated with decreases in cerebral vasoreactivity and vasodilation in the diabetic subjects, but not in controls.
"Normal blood flow regulation allows the brain to redistribute blood to areas of the brain that have increased activity while performing certain tasks," senior author Dr. Vera Novak, of Beth Israel Deaconess Medical Center in Boston, said in a news release. "People with type 2 diabetes have impaired blood flow regulation. Our results suggest that diabetes and high blood sugar impose a chronic negative effect on cognitive and decision-making skills."
The study's final analysis involved 40 people, average age 69, including 19 with diabetes and 21 controls. The diabetes patients had been treated for the disease an average of 13 years. Smokers were excluded.
The researchers administered a number of cognition and memory tests, magnetic resonance imaging (MRI) scans and blood tests at the beginning of the study and at 24 months.
At the two-year visit, the diabetics had lower global gray matter volume, lower composite scores on learning and memory, lower regional and global cerebral vasoreactivity, and worse glycemic control, compared to baseline.
Among the diabetics, impaired cerebral vasoreactivity at baseline correlated with worse performance of daily activities. In addition, worsening vasodilation correlated with greater decreases in executive function, independent of age, education, and other factors.
"Higher serum soluble intercellular and vascular adhesion molecules, higher cortisol, and higher C-reactive protein levels at baseline were associated with greater decreases in cerebral vasoreactivity and vasodilation only in the (diabetes) group, independent of diabetes control and 24-hour blood pressure," the researchers wrote online July 8 in Neurology.
"Inflammation may further impair cerebral vasoregulation, which consequently accelerates decline in executive function and daily activities performance in older people with (diabetes)," they said.
"Early detection and monitoring of blood flow regulation may be an important predictor of accelerated changes in cognitive and decision-making skills," Dr. Novak said in the news release. She called for additional studies in a greater number of people and for a longer duration.
"We are currently starting a Phase 2-3 clinical trial to see if intranasal insulin could prevent/slow down cognitive decline," she told Reuters Health by email.
She also noted that while no specific treatment exists to prevent cognitive decline, healthy life styles help people to have less decline.
Large clinical trials have shown that even strict control of blood sugar does not prevent cognitive decline. The high fluctuation in blood glucose that occurs with diabetes damages the nerves of the brain, she said.
The study was funded by the National Institute on Aging, American Diabetes Association, Harvard Clinical and Translational Science Center and National Center for Research Resources.
NEW YORK - Inflammation may contribute to impaired cerebral vasoregulation in type 2 diabetes, research suggests.
In a two-year study, participants with type 2 diabetes experienced diminished regional and global vasoreactivity in the brain, as well as a decline in cognitive function and the ability to perform daily tasks.
Higher blood levels of inflammatory markers were correlated with decreases in cerebral vasoreactivity and vasodilation in the diabetic subjects, but not in controls.
"Normal blood flow regulation allows the brain to redistribute blood to areas of the brain that have increased activity while performing certain tasks," senior author Dr. Vera Novak, of Beth Israel Deaconess Medical Center in Boston, said in a news release. "People with type 2 diabetes have impaired blood flow regulation. Our results suggest that diabetes and high blood sugar impose a chronic negative effect on cognitive and decision-making skills."
The study's final analysis involved 40 people, average age 69, including 19 with diabetes and 21 controls. The diabetes patients had been treated for the disease an average of 13 years. Smokers were excluded.
The researchers administered a number of cognition and memory tests, magnetic resonance imaging (MRI) scans and blood tests at the beginning of the study and at 24 months.
At the two-year visit, the diabetics had lower global gray matter volume, lower composite scores on learning and memory, lower regional and global cerebral vasoreactivity, and worse glycemic control, compared to baseline.
Among the diabetics, impaired cerebral vasoreactivity at baseline correlated with worse performance of daily activities. In addition, worsening vasodilation correlated with greater decreases in executive function, independent of age, education, and other factors.
"Higher serum soluble intercellular and vascular adhesion molecules, higher cortisol, and higher C-reactive protein levels at baseline were associated with greater decreases in cerebral vasoreactivity and vasodilation only in the (diabetes) group, independent of diabetes control and 24-hour blood pressure," the researchers wrote online July 8 in Neurology.
"Inflammation may further impair cerebral vasoregulation, which consequently accelerates decline in executive function and daily activities performance in older people with (diabetes)," they said.
"Early detection and monitoring of blood flow regulation may be an important predictor of accelerated changes in cognitive and decision-making skills," Dr. Novak said in the news release. She called for additional studies in a greater number of people and for a longer duration.
"We are currently starting a Phase 2-3 clinical trial to see if intranasal insulin could prevent/slow down cognitive decline," she told Reuters Health by email.
She also noted that while no specific treatment exists to prevent cognitive decline, healthy life styles help people to have less decline.
Large clinical trials have shown that even strict control of blood sugar does not prevent cognitive decline. The high fluctuation in blood glucose that occurs with diabetes damages the nerves of the brain, she said.
The study was funded by the National Institute on Aging, American Diabetes Association, Harvard Clinical and Translational Science Center and National Center for Research Resources.
NEW YORK - Inflammation may contribute to impaired cerebral vasoregulation in type 2 diabetes, research suggests.
In a two-year study, participants with type 2 diabetes experienced diminished regional and global vasoreactivity in the brain, as well as a decline in cognitive function and the ability to perform daily tasks.
Higher blood levels of inflammatory markers were correlated with decreases in cerebral vasoreactivity and vasodilation in the diabetic subjects, but not in controls.
"Normal blood flow regulation allows the brain to redistribute blood to areas of the brain that have increased activity while performing certain tasks," senior author Dr. Vera Novak, of Beth Israel Deaconess Medical Center in Boston, said in a news release. "People with type 2 diabetes have impaired blood flow regulation. Our results suggest that diabetes and high blood sugar impose a chronic negative effect on cognitive and decision-making skills."
The study's final analysis involved 40 people, average age 69, including 19 with diabetes and 21 controls. The diabetes patients had been treated for the disease an average of 13 years. Smokers were excluded.
The researchers administered a number of cognition and memory tests, magnetic resonance imaging (MRI) scans and blood tests at the beginning of the study and at 24 months.
At the two-year visit, the diabetics had lower global gray matter volume, lower composite scores on learning and memory, lower regional and global cerebral vasoreactivity, and worse glycemic control, compared to baseline.
Among the diabetics, impaired cerebral vasoreactivity at baseline correlated with worse performance of daily activities. In addition, worsening vasodilation correlated with greater decreases in executive function, independent of age, education, and other factors.
"Higher serum soluble intercellular and vascular adhesion molecules, higher cortisol, and higher C-reactive protein levels at baseline were associated with greater decreases in cerebral vasoreactivity and vasodilation only in the (diabetes) group, independent of diabetes control and 24-hour blood pressure," the researchers wrote online July 8 in Neurology.
"Inflammation may further impair cerebral vasoregulation, which consequently accelerates decline in executive function and daily activities performance in older people with (diabetes)," they said.
"Early detection and monitoring of blood flow regulation may be an important predictor of accelerated changes in cognitive and decision-making skills," Dr. Novak said in the news release. She called for additional studies in a greater number of people and for a longer duration.
"We are currently starting a Phase 2-3 clinical trial to see if intranasal insulin could prevent/slow down cognitive decline," she told Reuters Health by email.
She also noted that while no specific treatment exists to prevent cognitive decline, healthy life styles help people to have less decline.
Large clinical trials have shown that even strict control of blood sugar does not prevent cognitive decline. The high fluctuation in blood glucose that occurs with diabetes damages the nerves of the brain, she said.
The study was funded by the National Institute on Aging, American Diabetes Association, Harvard Clinical and Translational Science Center and National Center for Research Resources.
Triple Therapy May Increase Major Bleeding in Older Patients with Acute MI, AF
NEW YORK - Compared with dual antiplatelet therapy (DAPT), triple therapy increases the risk of major bleeding without altering the rates of myocardial infarction (MI), stroke, or death in older patients with acute MI and atrial fibrillation (AF), according to a registry study.
"These data suggest that the risk-benefit ratio of triple therapy in older patients with myocardial infarction and atrial fibrillation should be carefully considered," Dr. Connie N. Hess, from Duke Clinical Research Institute, Duke University, Durham, North Carolina, told Reuters Health by email. "However, these results need to be confirmed with prospective studies; a number of ongoing randomized clinical trials may help to provide insight."
Therapeutic decisions for older patients with acute MI and AF are challenging, not least because they have been excluded from or underrepresented in clinical trials.
Dr. Hess's team linked data from the ACTION Registry Get With The Guidelines and Medicare administrative claims to compare outcomes with DAPT or triple therapy (DAPT plus warfarin) in 4959 patients age 65 and older with acute MI and AF who underwent coronary stenting.
More patients were discharged on DAPT (72.4%) than on triple therapy (27.6%), the researchers report in the August 11 issue of the Journal of the American College of Cardiology (JACC), available online now.
The primary effectiveness outcome, major adverse cardiac events (MACE, including death or readmission for MI or stroke) at two years, did not differ in incidence between triple therapy (32.6%) and DAPT (32.7%), and there were no significant differences in the incidences of the individual MACE components.
In contrast, the cumulative incidence of bleeding requiring hospitalization within two years of discharge was significantly higher for patients on triple therapy (17.6%) than for patients on DAPT (11.0%; p<0.0001), and this difference persisted after adjustment for case-mix, treatment, and hospital features.
Triple therapy was also associated with a 2.04-fold higher risk of intracranial hemorrhage, compared with DAPT.
The association of triple therapy with MACE and bleeding outcomes was similar for patients older and younger than 75, for men and women, for patients with low and high predicted stroke risk, for patients with shorter versus longer duration of AF, for patients treated with drug-eluting versus bare-metal stents, and for patients presenting with non-ST-segment elevation MI versus ST-segment elevation MI.
"Until we have data from prospective studies to define optimal antithrombotic use in older patients with myocardial infarction and atrial fibrillation, providers should be especially mindful of an individual's bleeding risk when deciding to prescribe triple therapy," Dr. Hess concluded.
Dr. John C. Messenger, from the University of Colorado School of Medicine, Aurora, cowrote an editorial related to this report. He told Reuters Health by email, "We should ideally look to minimize duration of triple therapy, keeping it as short as possible. We also need to enroll patients in trials designed to evaluate double therapy without the use of aspirin."
"With the change in guidelines recommending oral anticoagulation for patients with atrial fibrillation at lower risk for ischemic stroke, the negative impact of bleeding related to the use of triple therapy may far outweigh the benefit of reduction of ischemic stroke," Dr. Messenger said. "We obviously need further study on this topic."
Dr. Andrea Rubboli, from Ospedale Maggiore, Bologna, Italy, has researched how best to treat these patients. He told Reuters Health by email, "Given that I practice in Europe, where current guidelines recommend triple therapy for these patients, what I found most surprising is the relatively small proportion of AF patients treated with (percutaneous coronary intervention) PCI who were discharged on triple therapy. Conversely, it was not surprising that DAPT was comparable to triple therapy in terms of MACE and superior in terms of bleeding because this has been previously reported and the several limitations of this kind of analysis (especially the lack of information on the therapy really ongoing at the time of event) may account for that."
"Triple therapy confirmed to be the best treatment for these patients," Dr. Rubboli concluded. "While not reducing MACE versus DAPT, it is indeed significantly more effective in reducing the most feared and devastating complication of AF, that is, stroke. Given the increased risk of bleeding, however, great care should be put in monitoring such therapy."
Dr. Nikolaus Sarafoff, from Ludwig-Maximilians University, Munich, Germany, told Reuters Health by email, "In my opinion, one major limitation of the study is that only 7.7% of patients in the DAPT group were on oral anticoagulation (OAC) at randomization as compared to 62.1% in the triple arm. This shows clearly that physicians felt that patients in the DAPT arm had no real indication for OAC (even before the myocardial infarction with PCI occurred) and this makes the comparison of the two groups very difficult."
"The indication for triple therapy and the optimal antithrombotic treatment should be taken carefully, weighing the bleeding and the ischemic risk of the patient," Dr. Sarafoff concluded. "Several options to reduce bleeding complications in this high-risk population exist, such as omitting aspirin, shortening the duration of therapy. The results of the present study cannot supplant current guidelines that state clearly that patients with atrial fibrillation and a CHA2DS2-VASc Score 2 are in need of OAC no matter whether concomitant antiplatelet therapy is needed."
The American College of Cardiology Foundation's National Cardiovascular Data Registry supported this study. Three coauthors reported relevant relationships.
NEW YORK - Compared with dual antiplatelet therapy (DAPT), triple therapy increases the risk of major bleeding without altering the rates of myocardial infarction (MI), stroke, or death in older patients with acute MI and atrial fibrillation (AF), according to a registry study.
"These data suggest that the risk-benefit ratio of triple therapy in older patients with myocardial infarction and atrial fibrillation should be carefully considered," Dr. Connie N. Hess, from Duke Clinical Research Institute, Duke University, Durham, North Carolina, told Reuters Health by email. "However, these results need to be confirmed with prospective studies; a number of ongoing randomized clinical trials may help to provide insight."
Therapeutic decisions for older patients with acute MI and AF are challenging, not least because they have been excluded from or underrepresented in clinical trials.
Dr. Hess's team linked data from the ACTION Registry Get With The Guidelines and Medicare administrative claims to compare outcomes with DAPT or triple therapy (DAPT plus warfarin) in 4959 patients age 65 and older with acute MI and AF who underwent coronary stenting.
More patients were discharged on DAPT (72.4%) than on triple therapy (27.6%), the researchers report in the August 11 issue of the Journal of the American College of Cardiology (JACC), available online now.
The primary effectiveness outcome, major adverse cardiac events (MACE, including death or readmission for MI or stroke) at two years, did not differ in incidence between triple therapy (32.6%) and DAPT (32.7%), and there were no significant differences in the incidences of the individual MACE components.
In contrast, the cumulative incidence of bleeding requiring hospitalization within two years of discharge was significantly higher for patients on triple therapy (17.6%) than for patients on DAPT (11.0%; p<0.0001), and this difference persisted after adjustment for case-mix, treatment, and hospital features.
Triple therapy was also associated with a 2.04-fold higher risk of intracranial hemorrhage, compared with DAPT.
The association of triple therapy with MACE and bleeding outcomes was similar for patients older and younger than 75, for men and women, for patients with low and high predicted stroke risk, for patients with shorter versus longer duration of AF, for patients treated with drug-eluting versus bare-metal stents, and for patients presenting with non-ST-segment elevation MI versus ST-segment elevation MI.
"Until we have data from prospective studies to define optimal antithrombotic use in older patients with myocardial infarction and atrial fibrillation, providers should be especially mindful of an individual's bleeding risk when deciding to prescribe triple therapy," Dr. Hess concluded.
Dr. John C. Messenger, from the University of Colorado School of Medicine, Aurora, cowrote an editorial related to this report. He told Reuters Health by email, "We should ideally look to minimize duration of triple therapy, keeping it as short as possible. We also need to enroll patients in trials designed to evaluate double therapy without the use of aspirin."
"With the change in guidelines recommending oral anticoagulation for patients with atrial fibrillation at lower risk for ischemic stroke, the negative impact of bleeding related to the use of triple therapy may far outweigh the benefit of reduction of ischemic stroke," Dr. Messenger said. "We obviously need further study on this topic."
Dr. Andrea Rubboli, from Ospedale Maggiore, Bologna, Italy, has researched how best to treat these patients. He told Reuters Health by email, "Given that I practice in Europe, where current guidelines recommend triple therapy for these patients, what I found most surprising is the relatively small proportion of AF patients treated with (percutaneous coronary intervention) PCI who were discharged on triple therapy. Conversely, it was not surprising that DAPT was comparable to triple therapy in terms of MACE and superior in terms of bleeding because this has been previously reported and the several limitations of this kind of analysis (especially the lack of information on the therapy really ongoing at the time of event) may account for that."
"Triple therapy confirmed to be the best treatment for these patients," Dr. Rubboli concluded. "While not reducing MACE versus DAPT, it is indeed significantly more effective in reducing the most feared and devastating complication of AF, that is, stroke. Given the increased risk of bleeding, however, great care should be put in monitoring such therapy."
Dr. Nikolaus Sarafoff, from Ludwig-Maximilians University, Munich, Germany, told Reuters Health by email, "In my opinion, one major limitation of the study is that only 7.7% of patients in the DAPT group were on oral anticoagulation (OAC) at randomization as compared to 62.1% in the triple arm. This shows clearly that physicians felt that patients in the DAPT arm had no real indication for OAC (even before the myocardial infarction with PCI occurred) and this makes the comparison of the two groups very difficult."
"The indication for triple therapy and the optimal antithrombotic treatment should be taken carefully, weighing the bleeding and the ischemic risk of the patient," Dr. Sarafoff concluded. "Several options to reduce bleeding complications in this high-risk population exist, such as omitting aspirin, shortening the duration of therapy. The results of the present study cannot supplant current guidelines that state clearly that patients with atrial fibrillation and a CHA2DS2-VASc Score 2 are in need of OAC no matter whether concomitant antiplatelet therapy is needed."
The American College of Cardiology Foundation's National Cardiovascular Data Registry supported this study. Three coauthors reported relevant relationships.
NEW YORK - Compared with dual antiplatelet therapy (DAPT), triple therapy increases the risk of major bleeding without altering the rates of myocardial infarction (MI), stroke, or death in older patients with acute MI and atrial fibrillation (AF), according to a registry study.
"These data suggest that the risk-benefit ratio of triple therapy in older patients with myocardial infarction and atrial fibrillation should be carefully considered," Dr. Connie N. Hess, from Duke Clinical Research Institute, Duke University, Durham, North Carolina, told Reuters Health by email. "However, these results need to be confirmed with prospective studies; a number of ongoing randomized clinical trials may help to provide insight."
Therapeutic decisions for older patients with acute MI and AF are challenging, not least because they have been excluded from or underrepresented in clinical trials.
Dr. Hess's team linked data from the ACTION Registry Get With The Guidelines and Medicare administrative claims to compare outcomes with DAPT or triple therapy (DAPT plus warfarin) in 4959 patients age 65 and older with acute MI and AF who underwent coronary stenting.
More patients were discharged on DAPT (72.4%) than on triple therapy (27.6%), the researchers report in the August 11 issue of the Journal of the American College of Cardiology (JACC), available online now.
The primary effectiveness outcome, major adverse cardiac events (MACE, including death or readmission for MI or stroke) at two years, did not differ in incidence between triple therapy (32.6%) and DAPT (32.7%), and there were no significant differences in the incidences of the individual MACE components.
In contrast, the cumulative incidence of bleeding requiring hospitalization within two years of discharge was significantly higher for patients on triple therapy (17.6%) than for patients on DAPT (11.0%; p<0.0001), and this difference persisted after adjustment for case-mix, treatment, and hospital features.
Triple therapy was also associated with a 2.04-fold higher risk of intracranial hemorrhage, compared with DAPT.
The association of triple therapy with MACE and bleeding outcomes was similar for patients older and younger than 75, for men and women, for patients with low and high predicted stroke risk, for patients with shorter versus longer duration of AF, for patients treated with drug-eluting versus bare-metal stents, and for patients presenting with non-ST-segment elevation MI versus ST-segment elevation MI.
"Until we have data from prospective studies to define optimal antithrombotic use in older patients with myocardial infarction and atrial fibrillation, providers should be especially mindful of an individual's bleeding risk when deciding to prescribe triple therapy," Dr. Hess concluded.
Dr. John C. Messenger, from the University of Colorado School of Medicine, Aurora, cowrote an editorial related to this report. He told Reuters Health by email, "We should ideally look to minimize duration of triple therapy, keeping it as short as possible. We also need to enroll patients in trials designed to evaluate double therapy without the use of aspirin."
"With the change in guidelines recommending oral anticoagulation for patients with atrial fibrillation at lower risk for ischemic stroke, the negative impact of bleeding related to the use of triple therapy may far outweigh the benefit of reduction of ischemic stroke," Dr. Messenger said. "We obviously need further study on this topic."
Dr. Andrea Rubboli, from Ospedale Maggiore, Bologna, Italy, has researched how best to treat these patients. He told Reuters Health by email, "Given that I practice in Europe, where current guidelines recommend triple therapy for these patients, what I found most surprising is the relatively small proportion of AF patients treated with (percutaneous coronary intervention) PCI who were discharged on triple therapy. Conversely, it was not surprising that DAPT was comparable to triple therapy in terms of MACE and superior in terms of bleeding because this has been previously reported and the several limitations of this kind of analysis (especially the lack of information on the therapy really ongoing at the time of event) may account for that."
"Triple therapy confirmed to be the best treatment for these patients," Dr. Rubboli concluded. "While not reducing MACE versus DAPT, it is indeed significantly more effective in reducing the most feared and devastating complication of AF, that is, stroke. Given the increased risk of bleeding, however, great care should be put in monitoring such therapy."
Dr. Nikolaus Sarafoff, from Ludwig-Maximilians University, Munich, Germany, told Reuters Health by email, "In my opinion, one major limitation of the study is that only 7.7% of patients in the DAPT group were on oral anticoagulation (OAC) at randomization as compared to 62.1% in the triple arm. This shows clearly that physicians felt that patients in the DAPT arm had no real indication for OAC (even before the myocardial infarction with PCI occurred) and this makes the comparison of the two groups very difficult."
"The indication for triple therapy and the optimal antithrombotic treatment should be taken carefully, weighing the bleeding and the ischemic risk of the patient," Dr. Sarafoff concluded. "Several options to reduce bleeding complications in this high-risk population exist, such as omitting aspirin, shortening the duration of therapy. The results of the present study cannot supplant current guidelines that state clearly that patients with atrial fibrillation and a CHA2DS2-VASc Score 2 are in need of OAC no matter whether concomitant antiplatelet therapy is needed."
The American College of Cardiology Foundation's National Cardiovascular Data Registry supported this study. Three coauthors reported relevant relationships.
LISTEN NOW: Tales from the Research, Innovations, and Clinical Vignette (RIV) Poster Competition
Hospitalists who presented RIV posters at HM15 talk about their projects. Dr. Brian Poustinchian worked on a bedside rounding study at Midwestern University in Illinois, and Dr. Jennifer Pascoe worked on a poster about patients leaving the hospital against medical advice, focusing on a case of her own at the University of Rochester.
Hospitalists who presented RIV posters at HM15 talk about their projects. Dr. Brian Poustinchian worked on a bedside rounding study at Midwestern University in Illinois, and Dr. Jennifer Pascoe worked on a poster about patients leaving the hospital against medical advice, focusing on a case of her own at the University of Rochester.
Hospitalists who presented RIV posters at HM15 talk about their projects. Dr. Brian Poustinchian worked on a bedside rounding study at Midwestern University in Illinois, and Dr. Jennifer Pascoe worked on a poster about patients leaving the hospital against medical advice, focusing on a case of her own at the University of Rochester.
Similar Early Outcomes in nvAF Regardless of Anticoagulant Type
NEW YORK - In the early months of anticoagulant treatment, patients with nonvalvular atrial fibrillation (nvAF) have similar rates of bleeding and arterial clots with dabigatran, rivaroxaban and vitamin K antagonists (VKA) like warfarin, researchers from France report.
Large randomized trials have shown the newer non-VKA oral anticoagulants (NOAC) to have superior safety and efficacy relative to warfarin, but subsequent observational studies have yielded conflicting results.
Dr. Géric Maura from National Health Insurance (CNAMTS) in Paris and colleagues used the French National Health Insurance information system to assess the bleeding and arterial thrombotic risks of dabigatran and rivaroxaban, each compared with VKA, during the first few months of therapy in 32,807 newly treated patients with nvAF.
There was no significant difference in bleeding between VKA- and dabigatran- or rivaroxaban-treated patients on propensity-matched analysis, regardless of whether patients were treated with low or high doses of each NOAC, the researchers report in Circulation, online July 21.
The composite outcome comprising hospitalization for bleeding and death occurred with similar frequency in the different treatment groups.
Among the secondary endpoints, there were no significant differences between treatments in arterial thromboembolic events or in the composite outcome comprising stroke, systemic embolism and death.
"Although our overall results are reassuring in relation to initiation of NOAC in nvAF patients in France with no marked excess thromboembolic or bleeding risk, they also suggest that particular caution is required when initiating NOAC," the researchers conclude. "But on the basis of this study comparing NOAC to VKA, NOAC cannot be considered to be safer than VKA during the early phase of treatment. On the contrary, the clinical implications of our results are that physicians must be just as cautious when initiating NOAC as when initiating VKA, particularly in view of the absence of an antidote and objective monitoring of the extent of anticoagulation."
"Similar analyses should be extended to other NOAC such as apixaban and observational studies should now focus on NOAC head-to-head comparison in a non-inferiority design," they suggest.
The study had no commercial funding and the authors reported no conflicts of interest.
Dr. Maura did not respond to a request for comment.
NEW YORK - In the early months of anticoagulant treatment, patients with nonvalvular atrial fibrillation (nvAF) have similar rates of bleeding and arterial clots with dabigatran, rivaroxaban and vitamin K antagonists (VKA) like warfarin, researchers from France report.
Large randomized trials have shown the newer non-VKA oral anticoagulants (NOAC) to have superior safety and efficacy relative to warfarin, but subsequent observational studies have yielded conflicting results.
Dr. Géric Maura from National Health Insurance (CNAMTS) in Paris and colleagues used the French National Health Insurance information system to assess the bleeding and arterial thrombotic risks of dabigatran and rivaroxaban, each compared with VKA, during the first few months of therapy in 32,807 newly treated patients with nvAF.
There was no significant difference in bleeding between VKA- and dabigatran- or rivaroxaban-treated patients on propensity-matched analysis, regardless of whether patients were treated with low or high doses of each NOAC, the researchers report in Circulation, online July 21.
The composite outcome comprising hospitalization for bleeding and death occurred with similar frequency in the different treatment groups.
Among the secondary endpoints, there were no significant differences between treatments in arterial thromboembolic events or in the composite outcome comprising stroke, systemic embolism and death.
"Although our overall results are reassuring in relation to initiation of NOAC in nvAF patients in France with no marked excess thromboembolic or bleeding risk, they also suggest that particular caution is required when initiating NOAC," the researchers conclude. "But on the basis of this study comparing NOAC to VKA, NOAC cannot be considered to be safer than VKA during the early phase of treatment. On the contrary, the clinical implications of our results are that physicians must be just as cautious when initiating NOAC as when initiating VKA, particularly in view of the absence of an antidote and objective monitoring of the extent of anticoagulation."
"Similar analyses should be extended to other NOAC such as apixaban and observational studies should now focus on NOAC head-to-head comparison in a non-inferiority design," they suggest.
The study had no commercial funding and the authors reported no conflicts of interest.
Dr. Maura did not respond to a request for comment.
NEW YORK - In the early months of anticoagulant treatment, patients with nonvalvular atrial fibrillation (nvAF) have similar rates of bleeding and arterial clots with dabigatran, rivaroxaban and vitamin K antagonists (VKA) like warfarin, researchers from France report.
Large randomized trials have shown the newer non-VKA oral anticoagulants (NOAC) to have superior safety and efficacy relative to warfarin, but subsequent observational studies have yielded conflicting results.
Dr. Géric Maura from National Health Insurance (CNAMTS) in Paris and colleagues used the French National Health Insurance information system to assess the bleeding and arterial thrombotic risks of dabigatran and rivaroxaban, each compared with VKA, during the first few months of therapy in 32,807 newly treated patients with nvAF.
There was no significant difference in bleeding between VKA- and dabigatran- or rivaroxaban-treated patients on propensity-matched analysis, regardless of whether patients were treated with low or high doses of each NOAC, the researchers report in Circulation, online July 21.
The composite outcome comprising hospitalization for bleeding and death occurred with similar frequency in the different treatment groups.
Among the secondary endpoints, there were no significant differences between treatments in arterial thromboembolic events or in the composite outcome comprising stroke, systemic embolism and death.
"Although our overall results are reassuring in relation to initiation of NOAC in nvAF patients in France with no marked excess thromboembolic or bleeding risk, they also suggest that particular caution is required when initiating NOAC," the researchers conclude. "But on the basis of this study comparing NOAC to VKA, NOAC cannot be considered to be safer than VKA during the early phase of treatment. On the contrary, the clinical implications of our results are that physicians must be just as cautious when initiating NOAC as when initiating VKA, particularly in view of the absence of an antidote and objective monitoring of the extent of anticoagulation."
"Similar analyses should be extended to other NOAC such as apixaban and observational studies should now focus on NOAC head-to-head comparison in a non-inferiority design," they suggest.
The study had no commercial funding and the authors reported no conflicts of interest.
Dr. Maura did not respond to a request for comment.